Welcome to Our Office

First Name

Last Name

Date of birth

Home Phone

Mobile

P.O Box

Current Address

Occupation

Employed by

Date of last complete eye examination

Refered by whom

Hobbies/Pastime

Complete below if patient is younger than 18 years of age

Name of Father/Mother/Guardian

Employer

Address

P.O Box

Work Phone

Health information

Please give names of any medications you are taking?

	Yes	No
Do you wear glasses?

How old are your glasses?

	Yes	No
Do you now or have you ever worn contact lenses?

	Disposable	Non Disposable	RGP
Type of contact lenses

	Yes	No
Have you ever had any eye surgeries?

	Yes	No
Do you work with a computer?

Personalization Settings (Optional)

Answer the questions below so we can better serve your needs. Over time, we'll be better able to offer up products and information that you care most about.

Person who is primary to your insurance

First Name

Last Name

Address

Address Line 1

Address Line 2

City

Country

Relationship to patiente

Phone/Mobile

DOB

NI#

Vision insurance

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE: I authorize the realise of any medical or other information necessary to process my insurance claim. I also request of government benefits either to myself or to the party who accepts assignment.

INSURED'S OR AUTHORIZED PERSON'S SIGNATURE: I authorize payment of medical benefits to Imperial Optical Co LTD. for services rendered.

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In case of an emergency, name of closest living friend or relative not living with you

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Checkbox Field

I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. Payment is due when services are rendered. Materials ordered (i.e glasses or contact lenses) require a deposit of 60% with the balance due upon delivery. We will assist you in completing any insurance forms so that you may be reimbursed from your insurance carrier. This office cannot accept responsibility for collecting your insurance claim. There will be a $30.00 fee on returned checks.

Date / Time

	Self	Relative
Glaucoma
Diabetes
Headaches
High Blood Pressure
Night Driving Problems
Cataracts
Blidness

	Self	Relative
Retinal Disease
Sickle Cell
Allergies
Asthma
Heart Conditions
Sinus Infections
Kidney Disease

	Self	Relative
Thyroid Disorders
Lupus
Psychiatric Problems
Arthritis
Cholesterol
Seizures

Welcome to Our Office

Health information

Personalization Settings (Optional)

Person who is primary to your insurance

Let us recommend the right lenses for you today

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